This document provides information on auscultation of the chest during a physical examination. It discusses the process of chest auscultation using a stethoscope and describes normal and abnormal breath sounds that may be heard. Specific points on the chest are identified for listening to breath sounds. Normal breath sounds as well as different types of abnormal breath sounds such as bronchial, decreased, and adventitious sounds like crackles, rhonchi and wheezes are defined. Extrapulmonary sounds and voice sounds that can be assessed during auscultation are also outlined.

1. CENTRE FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES
JAMIA MILLIA ISLAMIA
Presentation of Physiotherapy in Cardiopulmonary Conditions
TOPIC- AUSCULTATION: CHEST
Submitted to- Dr. JAMAL ALI MOIZ
Submitted by- ZUHA FAROOQ
BPT 4th YEAR
PRESENTATION DATE- 19.02.2021

2. Auscultation:-
Chest auscultation is the process of listening to and interpreting the sounds produced within the
thorax. It is an integral part of physical examination of a patient and is routinely used to provide
strong evidence in including or excluding different pathological conditions that are manifested
clinically in the patient.
Stethoscope:-
A stethoscope simplifies auscultation and facilitates localization
of any abnormalities. It consists of a diaphragm and bell connected
by tubing to two ear-pieces. The diaphragm is generally used for
listening to breath sounds, whilst the bell is best for the very low
frequencies generated by the heart (especially the third and fourth
heart sounds). The diaphragm and bell must be intact for a sound to
be heard properly, and the tubing relatively short to minimize absorption
of the sound. The ear-pieces, made of plastic or rubber, should fit within
the ears, pointing slightly forward in order to maximize sound transmission
into the auditory canal.

3. Auscultation procedure:-
• Chest auscultation should ideally be performed in a quiet room, with the chest exposed. The patient is instructed
to take deep breaths through an open mouth, as turbulence within the nose can interfere with the breath sounds.
There is a wide variation in the intensity of breath sounds depending on chest wall thickness.
• Listen to both the anterior and posterior sides of the chest.
• Start at the top and work your way to the bottom of the chest while comparing sides.
• When listen observe the following:-
• A full inspiration and expiration cycle.
• The inspiration and expiration sound pitch, quality, duration, and if it is normal sounding.
• Note for anything weird heard along with the inspiration and expiration. For example- crackles or wheezes.
• Have the patient sitting up with arms resting on lap. When listening to the posterior side of the chest the arms
need to be in the lap so the scapulae are separated.
• Use the diaphragm of the stethoscope to auscultate at various locations.
• Have patient breathe in and out through mouth slowly while listening.
• Allow the patient to set the pace to prevent hyperventilating, especially patients with breathing disorders like
COPD.

4. Lung Auscultation Points
Anterior:-
• Start at the apex of the lung which is right above the clavicle.
• Then 2nd intercostal space to assess the right and left upper lobes.
• At the 4th intercostal space to assess the right middle lobe and left upper lobe.
• Midaxillary at the 6th intercostal space assessing the right and left lower lobes.
Posterior:-
• Start right above the scapulae to listen to the apex of the lungs.
• Then find C7 and go to T3 in between the shoulder blades and spine to assess the right and left upper lobes.
• Then from T3 to T10 assess for the right and left lower lobes.

6. Chest sounds:-
Breath sounds-
• Normal
• Abnormal
• Adventitious
Extrapulmonary sounds-
• Pleural or friction rubs
Voice sounds-
• Egophony
• Bronchophony
• Whispered pectoriloquy
Heart sounds

7. Normal breath sounds:-
• Normal breath sounds are generated by turbulent airflow in the trachea and large airways.
• These sounds, which can be heard directly over the trachea, comprise high, medium and low frequencies.
• The higher frequencies are attenuated by normal lung tissue so that breath sounds heard over the periphery are
softer and lower pitched.
• Originally it was thought that the higher-pitched sounds were generated by the bronchi (bronchial breath
sounds) and the lower ones by airflow into the alveoli (vesicular breath sounds).
• It is now known that normal breath sounds (previously called 'vesicular') simply represent filtering of the
'bronchial' breath sounds generated in the large airways.
• Normal breath sounds are heard all over the chest wall throughout inspiration and for a short period during
expiration.

8. Breath sounds:-
Bronchial sound:-
• Auscultated over anterior chest and heard over trachea area.
• blowing, hollow, or tubular quality
• Expiratory sound longer in duration than inspiration
• Pause exist between inspiration and expiration
• Expiration is higher in pitch and intensity
Bronchovesicular sound:-
• Auscultated anteriorly and posteriorly and heard over the bronchi.
• high pitched
• no pause between inspiration and expiration
• Expiratory sound is louder, longer and higher in pitch than inspiratory sound, and displays a hollow character.
• Best heard wherever the bronchi, or central lung tissue, are close to the surface, i.e. supraclavicular,
suprascapular (the apices), parasternal and interscapular (the bronchi).

9. Vesicular sounds:-
• Auscultated anteriorly and posteriorly and heard over peripheral lung fields.
• Restling or breezy
• Intensity of inspiration more than expiration
• Longer duration of inspiration
• Lower pitch of expiration
• No pause between inspiratory and expiratory sound
• These sounds have primary an inspiratory component, with initial one third of the expiratory phase audible.
• Their intensity is softer due to spongy lung tissue and cumulative effect of the air entry from numerous terminal
bronchioles. This sound reflects air entry in the alveoli has been provided.

11. Abnormal Breath Sounds
• Abnormal breath sounds can be described as change in sound transmission as a result of the underlying
pathological process.
• Sound is filtered by the lung tissue because these organs are air filled, thus sound dampened over the bases
more than over the apices.
• On the other hand, sound transmission enhanced when a liquid or solid is the medium.
• Types of abnormal breath sounds are:- bronchial, decreased and absent.
Bronchial
• Bronchial sounds occur in peripheral lung tissue when it become airless either partial or complete.
• In a consolidating type of pneumonia, the lung tissue “airless” because of the complete obstruction of
segmental or local bronchi by secretions.
• Sounds from the adjacent bronchi is enhanced and become high-pitched, and the expiratory component is
louder and pronounced.
• Compression of lung tissue from extrapulmonary source also produces breath sounds. Eg., compression
secondary to pleural fluid (effusion) or tumor. Tubular breathing sounds is a term used synonymous to mean
abnormal breathing sound.

12. Decreased and Absent:-
• Occurs when sound transmission is diminished or abolished.
• Occurs due to further diminished vesicular sounds and absent sounds means no sounds are audible.
• May caused by an internal pulmonary pathology or can be caused by an initially non pulmonary condition.
• E.g. emphysema, pulmonary fibrosis, tumors, neuromuscular weakness, thoracic post operative cases, obesity.
Adventitious Breath Sounds:-
• Adventitious breath sounds are extraneous noise produced over the bronchopulmonary tree and indication of
abnormal process or condition.
• Crackles (rales):- are clicking sounds heard during inspiration. They are caused by the opening of
previously closed alveoli and small airways during inspiration. Coarse, early inspiratory crackles occur when
bronchioles open (often heard in bronchiectasis and bronchitis), whilst fine, late inspiratory crackles occur
when alveoli and respiratory bronchioles open (often heard in pulmonary oedema and pulmonary fibrosis).
When severe, the late inspiratory crackles of pulmonary oedema and pulmonary fibrosis may become coarser
and commence earlier in inspiration.

13. Rhonchi:- low pitched but continuous sound, occur both in I & E. Attributed to an obstructive process in the
larger, more central airways. Snoring is a term used to describe its quality.
Wheezes:- continuous and high pitched, a hissing or whistling sound. Wheeze that occurs predominantly
during inspiration indicates bronchospasm, and during exhalation indicates secretion. A fixed, monophonic
wheeze is caused by a single obstructed airway, while polyphonic wheezes are due to widespread disease. The
pitch of the wheeze is directly related to the degree of narrowing, with high-pitched wheezes indicating near total
obstruction. Low-pitched, localized wheezes are caused by sputum retention and can change or clear after
coughing.
Extrapulmonary Sounds:-
• An adventitious sound that is nonpulmonary is the friction rub.
• It can be described as a rubbing or leathery sound, and it occurs during I & E.
• The sound is produced when the visceral (inner) pleura lining rubs against the parietal pleura and is a sign of a
primary pleural process, such as inflammation or neoplasm.
• Pain is associated with friction rub usually.

14. Voice Sounds:-
• Voice sounds are vibration through a stethoscope and produced by the speaking voice as it travels down the
tracheobronchial tree and through the lung parenchyma.
• These sounds, over the normal lung, are low-pitched and have a muffled or mumbled quality.
• The transmission of these vocal vibration can be increased, decreased or absent in the presence of an
underlying pulmonary pathologic process.
• Bronchophony:- described the phenomenon of increased vocal transmission. Words are louder and clearer.
E.g. in consolidation due to pneumonia. To assess this patient is asked to repeat “blue moon”, or “one, two,
three…”.
• Eugophony:- may also be present when there is increased transmission of vocal vibration. In this case patient
is asked to say “eee”. The underlying process distorts the “e” sound so that an “aaa” sound is heard over the
peripheral area. Eugophony coexisting with bronchophony.

15. Whisper voice sound:- also produce low-pitched vibration over the chest that are muffled by the normal
lung parenchyma. In whispered pectoriloquoy, these whispered voice sound become distinct and clear, “one, two,
three” or “ninety nine” are used to evaluate this sound. Can be present in absence of eugophony coexisting and
bronchophony. Helpful for identifying smaller or patchy areas of lung consolidation.

16. Reference:-
• Jennifer A. Pryor, Barbara A. Webber, Physiotherapy for Respiratory and Cardiac
Problems, 2nd Edition.